Patient History: Wellness Visit
Phone Number you can be reached at time of appointment
Date of appointment
Has Your address/telephone number changed?
Yes(if yes please enter below
Please enter new address/phone number(s) here:
My pet is here today for:
Fecal/intestinal parasite screen
Urinalysis (recommended for all patients over 9)
Anal gland expression
Other health concern(s)
Would you like an estimate for today's appointment?
When was the last dose of heartworm preventative given? What brand?
Are you interested in learning more about Proheart, (FOR DOGS ONLY) a single injection that prevents Heartworm disease for 12 months? Currently on Promotion!
Yes, I would like my pet to have Proheart
I'm interested in hearing more about Proheart
I'm not interested at this time
When was the last dose of flea/tick prevention given? What brand?
Do you have any concerns about getting your pet to our office or concerns about your pet's stress level during their visit?
Current diet (brand, wet/dry/both)
Please share any concerns or questions here
Covid 19 Questionaire
Have you or a family member tested positive for Covid-19 in the last 14 days?
Are you or any member of your household experiencing any of the following symptoms?
Fever of higher than 100.4, Loss of smell or taste, Difficulty breathing, Cough,Sore throat, Diarrhea, Vomiting, or any other symptom(s) of Covid 19?
If you have answered yes to any of these questions we ask that you postpone your visit at least 14 days from the start of your symptoms or have a non household member who does not have any Covid-19 symptoms bring your pet. Thank you for your understanding.
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